Hypothyroidism and Dysphonia

Kristin Kucera Marcum MD S Carter Wright Jr MD Catherine Rees Lintzenich MD

Department of Otolaryngology Center for Voice and Swallowing Disorders

Introduction The association between hypothyroidism and

dysphonia has been recognized since at least

19601 In animal models with induced

hypothyroidism an increased level of acid

mucopolysaccarides in the vocal fold

submucosa has been observed2 Although

these findings have not been reproduced in

human cadaver studies in myxedema the vocal

folds become edematous and demonstrate

Reinkersquos edema (polypoid degeneration)

Indeed the rate of hypothyroidism is higher in

patients with Reinkersquos edema than in the

general population3 In milder cases of

hypothyroidism vocal fold changes are less

striking The laryngeal examination can be

essentially normal in the hypothyroid patient

despite subjective dysphonia4

Evaluating thyroid stimulated hormone levels

has long been advocated in the work-up of

voice disorders and is routinely performed as

part of the standard of care in the Center for

Voice and Swallowing Disorders (CVSD) To

date there are no studies looking at the rate of

hypothyroidism in a large group of dysphonic

patients Overt hypothyroidism in the general

population is 03 but little data exists on

thyroid function levels in dysphonic patients

and the prevalence of undiagnosed thyroid

disease in patients with dysphonia is yet to be

determined5

This study aims to evaluate the prevalence of

previously undiagnosed hypothyroidism in

patients with a primary complaint of dysphonia

hoarseness or vocal fatigue We investigated

whether the prevalence of hypothyroidism in

this group differs significantly from the general

public

Materials and Methods

This study was approved by the Institutional

Research Board at Wake Forest University and

combines a prospective study and a

retrospective chart review The prospective

study collected data from medical records of

new andor existing patients that presented to

the Department of Otolaryngology Center for

Voice and Swallowing Disorders (CVSD) with a

complaint of dysphonia hoarseness andor

vocal fatigue from 2009 through present The

retrospective chart review captured data from

medical records from 2007 to 2009 when the

prospective data collection began

Results

951 new healthy adults presented to the

Wake Forest CVSD with a chief complaint

of dysphonia

154 patients met criteria to participate in

the study

Data collection included

Voice Handicap Index (VHI)

Age

Sex

Thyroid Stimulating Hormone level

(TSH)

There were a total of 111 females and 43

males

Average age was 569 years old average

BMI was 286 and average VHI was 188

The average TSH obtained from all

subjects was 197 mIUL (normal TSH 04-

55mIUL)

In the subject pool from CVSD 26 of

patients with a chief complaint of

dysphonia were found to have an

abnormally high TSH Of the patients

with TSH gt55 mIUL 50 were 60 years

of age or greater and 75 were female

Discussion If hypothyroidism is allowed to go untreated for a

prolonged period of time the soft tissues of the

body become edematous Myxedema increases

protein and acid mucopolysaccharide content of

connective tissue cells producing a viscid fluid

Most authors state progressive hoarseness in

patients with hypothyroidism is due to the

distorted edematous vocal folds caused by

laryngeal myxedema27 In milder cases of

hypothyroidism vocal changes are not as

obvious In fact the laryngeal examination is

frequently normal in the hypothyroid patient

despite subjective dysphonia4

Hoarseness affects nearly one-third of the

population at some point in their life11 The

National Health and Nutrition Examination Survey

of 4392 individuals reflecting the US population

reported overt hypothyroidism in 03 of the

population5 Our study reveals the prevalence of

thyroid disease in patients with a chief complaint

of dysphonia who present to the CVSD of 26

There was no association between age BMI or

VHI with TSH TSH and VHI were compared

using a tailed t-test there was weak to no

correlation and no linear association between

VHI and TSH (009 p=276) If symptoms as

measured by VHI are not a reliable method of

hypothyroidism disease severity it may make

dependence on the physical exam all the more

important

Currently the TSH cutoff for hypothyroidism at our

lab is 55 mIUL Our prevalence of

hypothyroidism at 26 was markedly elevated

over the general populationrsquos rate of 03

When grouped by age half of our hypothyroid

patients (as indicated by TSH gt55 mIUL) were

noted to be 60 years of age and older Although

we would advocate a thyroid work up for all

dysphonic patients without a physical exam

finding of paresis or paralysis an even greater

emphasis should be placed on the patient

population over 60 years old

Conclusions Our results suggest that hypothyroidism is more

prevalent in patients with dysphonia than in the

general population without dysphonia This

association is clinically relevant to the treatment

of patients who present with voice complaints

TSH is simple screening test for the

Otolaryngologist In patients with no obvious

physical exam finding to explain dysphonia or

with findings of myxedema a thorough exam and

clinical workup for thyroid disorders remains an

important part of the evaluation

References

1 Ficarra BJ Myxedatous hoarseness Arch Otolaryngol 19607275-6

2 Ritter FN The effect of hypothyroidism on the larynx of the rat an explanation for hoarseness

associated with hypothyroidism in the human Trans Am Laryngol Assoc 19648565-79

3 White A Sim DW Maran AG Reinkersquos oedema and thyroid function J Laryngol Otol

1991105(4)291-2

4 Gupta OP Bhatia PL Agarwal MK et al Nasal pharyngeal and laryngeal manifestations of

hypothyroidism Ear Nose Throat J 197756(9)349-56

5 Aoki Y Belin RM Clickner R Jeffries R Phillips L Mahaffey KR Serum TSH and Total T4 in the

United States Population and Their Association with Participant Characteristics National Health and

Nutrition Examination Survery (NHANES 1999-2002) Thyroid 2007 121211-1223

6 Lindholm J Laurberg P Hypothyroidism and thyroid subsititution historical aspects J Thyroid Res

20112011809341 Epub 2011 Jun 8

7 Frank N Ritter MD Ann Arbor MichThe effects of hypothyroidism upon the ear nose and throat A

clinical and experimental study Laryngoscope 1967771427-79

8 Bicknell PG Mild hypothyroidism and its effects on the larynx J Laryngol Otol 1973 87123-7

9 Altman KW Haines GK 3rd Vakkalanka SK Keni SP Kopp PA Radosevich JA Identification of

thyroid hormone receptors in the human larynx Laryngoscope 2003113(11)1931-4

10 Rapp MF Guram M Konrad HR Mody N Trapp R Laryngeal Involvement In Scleromyxedema A

Case Report Otolaryngol Head Neck Surg 1991104(3)362-5

11 Seth R Schwartz Seth M Cohen Seth H Dailey Richard M Rosenfeld Ellen S Deutsch M Boyd

Gillespie Evelyn Granieri Edie R Hapner C Eve Kimball Helene J Krouse J Scott McMurray Safdar

Medina Karen OBrien Daniel R Ouellette Barbara J Messinger-Rapport Robert J Stachler Steven

Strode Dana M Thompson Joseph C Stemple J Paul Willging et al Clinical Practice Guideline Oto

Head and Neck Surg 141 2009(3) S1-S32)

copy Creative Communications Wake Forest Baptist Health creativewakehealthedu

Permission is granted for use when printed by Creative Communications All other uses strictly prohibited

Abstract

Objectives Evaluating thyroid stimulating

hormone levels has long been advocated in the

work-up of voice disorders and is routinely

performed as part of the standard of care in the

Center for Voice and Swallowing Disorders

Overt hypothyroidism in the general population

is 03 but little data exists on thyroid function

levels in dysphonic patients The prevalence of

undiagnosed thyroid disease in patients with

dysphonia is yet to be determined We

investigated whether the prevalence of

hypothyroidism in this group differs significantly

from the general public

Study Design Prospective study with

retrospective chart review

Methods 951 healthy adults presented to the

Wake Forest Voice Center with a chief

complaint of dysphonia or hoarseness 154

patients met criteria for the study Data

collection included Voice Handicap Index (VHI)

age sex and thyroid stimulating hormone level

(TSH)

Results The average TSH obtained from all

subjects was 197 mIUL (normal TSH 04-

55mIUL) In the subject pool from CVSD 26

of patients with a chief complaint of dysphonia

were found to have an abnormally high TSH

Conclusions Our results suggest that

hypothyroidism is more prevalent in patients

with dysphonia than in the general population

without dysphonia In these patients with no

obvious physical exam finding to explain

dysphonia or with findings of myxedema a

thorough exam and clinical workup for thyroid

disorders remains an important part of the

evaluation

951 patients presented to the CVSD with a new

complaint of hoarseness dysphonia or vocal

fatigue during the study period 154 patients

were identified as qualifying participants who met

all inclusion and exclusion criteria As part of the

patients routine scheduled clinic visit if thyroid

stimulating hormone level (TSH) had not been

ordered in the last 6 months a TSH lab draw

was obtained from each subject Demographic

information collected included gender age race

weight height and calculated BMI The TSH

level and the voice handicap index (VHI) score

were also obtained

All analyses were performed with Sigma Stat

35 SPSS (SPSS Inc Chicago) Estimates of

hypothesized rates of hypothyroidism were

obtained based on a One-Sample Binomial Test

A P value of lt05 was considered indicative of

statistical significance A power analysis was

completed 68 patients were needed to have a

90 chance of detecting a significant difference

using a two-sided test with p-value 005